Diphtheria: Questions and Answers

What causes diphtheria ?

Diphtheria is caused by a bacterium, Corynebacterium diphtheriae. The actual disease is caused when the bacteria release a toxin, or poison, into a person’s body.

How does diphtheria spread ?

Diphtheria bacteria live in the mouth, throat, and nose of an infected person and can be passed to others by coughing or sneezing. Occasionally, transmission occurs from skin sores or through articles soiled with oozing from sores of infected people.

How long does it take to show signs of diphtheria after being exposed ?

The incubation period is short: 2–5 days, with a range of 1–10 days.

What are the symptoms of diphtheria ?

Early symptoms of diphtheria may mimic a cold with a sore throat, mild fever, and chills. Usually, the disease causes a thick coating at the back of the throat, which can make it difficult to breathe or swallow. Other body sites besides the throat can also be affected, including the nose, larynx, eye, vagina, and skin.

How serious is diphtheria ?

Diphtheria is a serious disease: 5%–10% of all people with diphtheria die. Up to 20% of cases lead to death in certain age groups of individuals (e.g., children younger than age 5 years and adults older than age 40 years).

What are possible complications from diphtheria ?

Most complications of diphtheria are due to the release of the toxin, or poison. The most common complications are inflammation of the heart leading to abnormal heart rhythms, and inflammation of the nerves which may cause temporary paralysis of some muscles. If the paralysis affects the diaphragm (the major muscle for breathing), the patient may develop pneumonia or respiratory failure. The thick membrane coating at the back of the throat may cause serious breathing problems, including suffocation.

How do I know if someone has diphtheria ?

The diagnosis of diphtheria can only be confirmed after a physician takes a small sample of infected material from the patient’s throat (or other site) and has the sample tested in a laboratory. But because this disease progresses quickly, treatment usually should begin based on the health professional’s assessment of the patient.

Is there a treatment for diphtheria ?

Diphtheria is treated with both antibiotics and with diphtheria antitoxin. Diphtheria antitoxin is produced in horses and was first used in the United States in 1891. Antitoxin does not get rid of toxin that is already attached to the body’s tissues, but will neutralize any circulating poison and will prevent the disease from getting worse. The patient should be tested for sensitivity to this antitoxin before it is given.

How common is diphtheria in the United States ?

Diphtheria was once a greatly feared illness in the United States. In the 1920s, there were between 100,000 and 200,000 cases of diphtheria each year with 13,000–15,000 deaths. Because of widespread immunization and better living conditions, diphtheria is now rare in the United States (during 1998– 2009, seven cases of respiratory diphtheria were reported to CDC).

Recent surveys have found that immunity decreases with age, and only 30% of U.S. adults age 60–69 years are vaccinated against diphtheria. This is a concern because the disease continues to occur in other parts of the world. For example, after the breakup of the former Soviet Union, their vaccination rates fell, and large outbreaks of diphtheria began in 1990 in the Newly Independent States. From 1990 to 1998, more than 150,000 people got sick from diphtheria and more than 5,000 people died. This situation, and other outbreaks around the world, illustrates what can happen when vaccination levels fall. Outbreaks in other countries also increase the risk of diphtheria importation into the United States.

Can you get diphtheria more than once ?

Yes. Even individuals recovering from diphtheria should be immunized against the disease as soon as possible.

When did vaccine first become available for diphtheria, tetanus, and pertussis ?

The first inactivated toxin, or toxoid, against diphtheria was developed around 1921, but it was not widely used until the 1930s. In 1924, the first tetanus toxoid (inactivated toxin) was produced and was used successfully to prevent tetanus in the armed services during World War II. The first pertussis vaccine was developed in the 1930s and was in widespread use by the mid-1940s, when pertussis vaccine was combined with diphtheria and tetanus toxoids to make the combination DTP vaccine. A series of 4 doses of whole-cell DTP vaccine was quite (70–90%) effective in preventing serious pertussis disease; however, up to half of the children who received the vaccine developed local reactions such as redness, swelling, and pain at the injection site. In 1991, concerns about safety led to the development of more purified (acellular) pertussis vaccines that are associated with fewer side effects. These acellular pertussis vaccines have replaced the whole cell DTP vaccines in the U.S.

In 2005, two new vaccine products were licensed for use in adolescents and adults that combine the tetanus and diphtheria toxoids with acellular pertussis (Tdap) vaccine. These vaccines are the first acellular pertussis-containing vaccines that make it possible to vaccinate adolescents and adults against pertussis.

How are vaccines made that prevent diphtheria, tetanus and pertussis ?

These vaccines are made by chemically treating the diphtheria, tetanus, and pertussis toxins to render them nontoxic yet still capable of eliciting an immune response in the vaccinated person. They are known as “inactivated” vaccines because they do not contain live bacteria and cannot replicate themselves, which is why multiple doses are needed to produce immunity.

What’s the difference between all the vaccines containing diphtheria and tetanus toxoids and pertussis vaccine ?

It’s like alphabet soup! Here is a listing of the various products:

• DTaP: Diphtheria and tetanus toxoids and acellular pertussis vaccine; given to infants and children ages 6 weeks through 6 years. In addition, three childhood combination vaccines include DTaP as a component.

• DT: Diphtheria and tetanus toxoids, without the pertussis component; given to infants and children ages 6 weeks through 6 years who have a contraindication to the pertussis component.

• Tdap: Tetanus and diphtheria toxoids with acellular pertussis vaccine; given to adolescents and adults, usually as a single dose; the exception is pregnant women who should receive Tdap during each pregnancy.

• Td: Tetanus and diphtheria toxoids; given to children and adults ages 7 years and older. Note the small “d” which indicates a much smaller quantity of diphtheria toxoid than in the pediatric DTaP formulation.

How are these vaccines given ?

The DTaP and DT preparations are all given as an injection in the anterolateral thigh muscle (for infants and young toddlers) or in the deltoid muscle (for older children and adults). Tdap and Td are given in the deltoid muscle for children and adults age 7 years and older.

Who should get these vaccines ?

All children, beginning at age 2 months, and adults need protection against these three diseases—diphtheria, tetanus, and pertussis (whooping cough). Routine booster doses are also needed throughout life.

How many doses of vaccine are needed ?

The usual schedule for infants is a series of four doses of DTaP given at 2, 4, 6, and 15–18 months of age. A fifth shot, or booster dose, is recommended between age 4 and 6 years, unless the fourth dose was given late (after the fourth birthday).

For people who were never vaccinated or who may have started but not completed a series of shots, a 3-dose series of Td should be given with 1 to 2 months between dose #1 and #2, and 6 to 12 months between dose #2 and #3. One of the doses, preferably the first, should also contain the pertussis component in the form of Tdap.

Because immunity to diphtheria and tetanus wanes with time, boosters of Td are needed every ten years.

When adolescents and adults are scheduled for their routine tetanus and diphtheria booster, should they get vaccinated with Td or Tdap ?

Immunization experts recommend that the first dose of Tdap be given to all adolescents at age 11–12 years as a booster during the routine adolescent immunization visit if the adolescent has finished the childhood DTaP schedule and has not already received a dose of Td or Tdap. If a child age 7–10 years did not complete a primary series in childhood, a dose of Tdap may be given earlier as part of the catch-up vaccinations.

All adults should receive a single dose of Tdap as soon as feasible. Then, subsequent booster doses of Td should be given every ten years. Pregnant teens and women should receive Tdap during each pregnancy. Adolescents and adults who have recently received Td vaccine can be given Tdap without any waiting period.

If someone experiences a deep or puncture wound, or a wound contaminated with dirt, an additional booster dose may be given if the last dose was more than five years ago. This could be a dose of Td or Tdap, depending on the person’s vaccination history. It is important to keep an up-to-date record of all immunizations so that repeat doses don’t become necessary. Although it is vital to be adequately protected, receiving more doses than recommended can lead to increased local reactions, such as painful swelling of the arm.

Who recommends the use of these vaccines ?

The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) all recommend this vaccine.

What side effects have been reported with these vaccines ?

Local reactions, such as fever, redness and swelling at the injection site, and soreness and tenderness where the shot was given, are not uncommon in children and adults. These minor local and systemic adverse reactions are much less common with acellular DTaP vaccine; however, a determination of more rare adverse effects can only be made when additional data are available following extended use of DTaP.

Side effects following Td or Tdap in older children and adults include redness and swelling at the injection site (following Td) and generalized body aches, and tiredness (following Tdap). Older children and adults who received more than the recommended doses of Td/Tdap vaccine can experience increased local reactions, such as painful swelling of the arm. This is due to the high levels of tetanus antibody in their blood.

How effective are these vaccines ?

After a properly spaced primary series of DTaP or Td/ Tdap, approximately 95% of people will have protective levels of diphtheria antitoxin and 100% will have protective levels of tetanus antitoxin in their blood. However, antitoxin levels decrease with time so routine boosters with tetanus and diphtheria toxoids are recommended every 10 years. Estimates of acellular pertussis vaccine efficacy range from 80% to 85%—a level believed to be far more efficacious than the previously-used whole cell pertussis vaccine.

Can a pregnant woman receive Tdap vaccine ? Yes. All pregnant women should receive Tdap during each pregnancy, preferably between 27 and 36 weeks’ gestation. Because infants are not adequately protected against pertussis until they have received at least 3 doses of DTaP, it is especially important that all contacts (family members, caregivers) of infants younger than age 12 months are vaccinated with Tdap. If a new mother hasn’t been vaccinated with Tdap, she should receive it before hospital discharge, even if she is breastfeeding.

Who should not receive these vaccines ?

Generally, any person who has had a serious allergic reaction to a vaccine component or a prior dose of the vaccine should not receive another dose of the same vaccine. People who had a serious allergic reaction to a previous dose of DTaP or Tdap vaccine should not receive another dose.

Certain rare adverse events following pertussis vaccination usually serve as a precaution against receiving further doses. Such events include a temperature of 105°F or higher within two days, collapse or shocklike state within two days, persistent crying for more than three hours within two days, or convulsions within three days. Even if one of these precautions exists, there may be occasions when the benefit of immunization outweighs the risk (for example, during a community-wide outbreak of pertussis).

A person who developed one of these adverse events after pediatric DTaP vaccine may receive Tdap as an adolescent or adult. A person with a recognized, possible, or potential neurologic condition should delay receiving DTaP or Tdap vaccine until the condition is evaluated, treated, and/or stabilized. Although DTaP vaccine does not cause neurological disorders, receiving the vaccine can cause an already-present underlying condition to show itself.

Can the vaccine cause the disease ?

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